Draft Commissioning Strategy for home support, supported living and residential care (with and without nursing)

Transcription

1 Draft Commissioning Strategy for home support, supported living and residential care (with and without nursing) Pricing Proposals What are the proposals the Council is considering? The Care Act (2014) introduced new duties for local authorities in England to facilitate and shape a diverse, sustainable market for quality care and support in their local area. The Council s Draft Commissioning Strategy, sets out the approach the Council is proposing to take from 1 April 2018 and to move to a fixed fee for the following services: Home support for children and young people with a disability and adults of all ages Residential care for adults of all ages Nursing care for adults of all ages Supported living (as defined by the Care Quality Commission) for adults of all ages It is proposed that the Council will operate a fixed fee approach, providing greater transparency of pricing and allowing all parties to plan more effectively. There will be separate fixed fees for each different category of care which are derived from a baseline understanding of the costs of providing adult social care in Birmingham which are summarised below. Comparison data The Council has undertaken a range of comparison and benchmarking activities to develop the proposed fees and to further understand the relative costs of care in Birmingham, including use of the following: KPMG s Open Book 3 analysis of the costs of care in Birmingham Detailed analysis of current pricing data held by the Council Regional market intelligence and costs of care for neighbouring areas The analysis provided by the provider Task and Finish Group which provided its analysis in September 2016 Page 1 of 17

2 The following graphs summarise the analysis used by the Council to consider the proposed prices from 1 April 2018 onwards taking into consideration a comparison of costs; between providers; between local authorities including similar authorities nationally and regionally; and between national and regional benchmarking. Home Support There are currently 203 registered home support providers in Birmingham, of which 114 are registered on the Council s current framework agreement (some will also provide extra care and supported living). 15 of those providers are projected to have received more than 1m in fees from the Council in 2016/17, while 28 will have received less than 10k in the same year. On 25th October 2016, the United Kingdom Home Care Association (UKHCA) published The Homecare Deficit This report also included some regional analysis which showed that Birmingham s average hourly rate for home care fell within the lower end of the sample group (local authorities in the West Midlands, and comparable (core city) councils across England). One of the reasons for the differences in the sample group is that the rural counties of Herefordshire, Worcestershire, Shropshire and Staffordshire will include higher levels of travel costs than might be expected within the urban areas such as Birmingham. As part of the provider engagement activity conducted in summer 2016 a Task & Finish Group was established to look at the cost of care in Birmingham. In this report, the conclusion was that home care cost per hour including a 20% operating return is Page 2 of 17

3 Figure 1 below shows firstly the core cities comparator data towards the left of the graph, moving to regional pricing on the right of the graph. The current Birmingham average (shown in red), the KPMG Open Book 3 mean fee (inflated to reflect 2016 prices and to include a profit margin) shown in green and the fee proposed by the provider Task and Finish Group in 2016 (shown in purple). It is important to note that the UKHCA s own rate is 16.70, significantly less than the rate suggested by the Task and Finish Group. The UKHCA s stated position is that the provider achieves a profit or surplus of 3%, which is just sufficient to enable a sustainable business, not the 20% suggested by the Task and Finish Group. However, taking the Task & Finish Group s proposal, a major element of the fee is 3.60 for travel (i.e. 8 miles for every hour of care delivered). This may well reflect a practice of using the Sproc.Net system to win packages outside of normal carer routes. If the 8 miles were reduced to 2 miles per hour call then the Task & Finish Group s proposal would be more closely aligned with the Council s current average fee and that suggested by the KPMG analysis in If we broadly accept the Task and Finish Group s costings, but at a lower number of miles for each hour of care, then the current Birmingham average fee within a geographic home support model and with a profit margin closer to the UKHCA s minimum of 3% would reflect local circumstances. Page 3 of 17

4 Supported living housing has been developed to meet diverse individual requirements and on the basis that many people with learning disabilities would prefer to choose who, if anyone, they wished to live with. There is an assumption that people with learning disabilities would generally prefer to live either in an individual flat or house, or to share, but only with a small number of other people, personally selected. Supported living enables individuals to make these choices and to have their own tenancies. Historically, supported living in Birmingham has been developed in very small clusters or with care and support being provided to isolated individuals who may not live near to each other. The Council has been working with supported living providers over the last few years to develop larger clusters of flats in close proximity and/or within small blocks of flats or converted buildings. This approach is designed to achieve economies of scale whilst ensuring that numbers of citizens sharing remain relatively small (Lang and Buisson: Illustrative Cost Models in Learning Disabilities Social Care Provision, 2011). Fee levels for supported living are varied in Birmingham and the Council has previously commissioned shared hours of additional support where service users are in the same building. This enables care providers to manage risks and offer ad hoc support when required and provides additional support which is beneficial to individuals. However, these shared hours do make it difficult to identify the true hourly cost of care. This is also true of other Councils who do not currently have a usual fee for supported living that can be provided for comparison purposes. However, as part of both the analysis conducted by KPMG in 2013 and the provider Task and Finish Group in 2016 a range of fees were identified for supported living. Figure 2 below does show the Council s current average fee for support living which may not fully reflect shared hours as detailed above (shown in red), KPMG Open Book 3 mean fee (inflated to reflect 2016 prices and to include a profit margin) shown in green and the fee proposed by the provider Task and Finish Group in 2016 (shown in purple). Page 4 of 17

5 The Council recognises the similarities between the costs of delivering care and support in supported living with that of home support, however, a major element of the Task and Finish Group and KPMG fees was travel time. Given the Council s current approach outlined above to continuing to develop larger clusters of supported living and the efficiencies and benefits this can bring, then a fee aligned to the home support fee with reduced travel time and costs would reflect local circumstances. Residential care for over 65 s There are currently 146 providers delivering residential care for over 65 s in Birmingham and a further 138 who deliver residential care to Birmingham citizen s that are outside of the City Council s boundary. Figure 3 below shows firstly the core cities comparator data towards the left of the graph, moving to regional pricing on the right of the graph. The current Birmingham average (shown in red), the KPMG Open Book 3 mean fee (inflated to reflect 2016 prices and to include a profit margin) shown in green and the fee proposed by the provider Task and Finish Group in 2016 (shown in purple). The Council s analysis shows that the current average price paid for residential care for over 65 s is largely above fees paid by other core cities. Regional data shows a similar picture, with obvious exceptions in Solihull, Derby and Warwickshire. The Council s investigations into increased prices Page 5 of 17

6 within Solihull have identified a shortage of supply of residential care homes, which is driving up the price paid per bed. The KPMG 2016 fee which uses the KPMG 2013 fee and inflates them to broadly 2016 levels is closely aligned with the Council s current average fee for residential care for over 65 s. The Task and Finish Group proposed fee includes a profit margin of 10% but unfortunately did not provide a breakdown of the assumed costs to allow the Council to conduct a more detailed analysis of any differences. In 2016 CIPFA released their report Working with care providers to understand costs which identified illustrative 2016 costs of residential care. Included within this report is a suggested Association of Directors of Adult Social Services (ADASS) 2016/17 fee rate of which again aligns with the Council s current average fee. The Council s analysis based on the broad range of information available shows that the current average fee for residential care for over 65 s would reflect local, regional and national circumstances. Residential care with nursing for over 65 s There are currently 68 providers delivering residential care with nursing for over 65 s in Birmingham and a further 43 who deliver residential care with nursing to Birmingham citizen s that are outside of the City Council s boundary. Figure 4 below shows firstly the core cities comparator data towards the left of the graph, moving to regional pricing on the right of the graph. The current Page 6 of 17

7 Birmingham average (shown in red), the KPMG Open Book 3 mean fee (inflated to reflect 2016 prices and to include a profit margin) shown in green and the fee proposed by the provider Task and Finish Group in 2016 (shown in purple). The Council s analysis shows that the current average fee for residential care with nursing for over 65 s is broadly aligned to fees paid by other core cities. Regional data shows Birmingham s current average above our neighbouring Council s fees, with an obvious exception in Solihull. The Council s investigations into increased prices within Solihull have identified a shortage of supply of residential care homes with nursing, which is driving up the price paid per bed. The KPMG 2016 fee which uses the KPMG 2013 fee and inflates them to broadly 2016 levels is closely aligned with the Council s current average fee for residential care with nursing for over 65 s. The Task and Finish Group proposed fee includes a profit margin of 10% but unfortunately did not provide a breakdown of the assumed costs to allow the Council to conduct a more detailed analysis of any differences. In 2016 CIPFA released their report Working with care providers to understand costs which identified illustrative 2016 costs of residential care and nursing care. Included within this report is a suggested Association of Directors of Adult Social Services (ADASS) 2016/17 fee rate of plus 151 nursing contribution was again aligned with the Council s current average fee. The Council s analysis based on the broad range of information available shows that they current average fee for residential care with nursing for over 65 s would reflect local, regional and national circumstances. Page 7 of 17

8 Residential care for year olds There are currently 108 care providers delivering residential care for year olds in Birmingham and a further 159 who deliver residential care to Birmingham citizen s that are outside of the City Council s boundary. The Council s analysis of fees paid to providers of adult social care for citizens aged between 18 and 64, shows that there are a wide range of tools and models for determining the fee to be paid. Many authorities do not have a set fee for care and support for year olds, just as is currently the case within Birmingham. This has made comparison with core cities and regional neighbours challenging., We have therefore focussed our analysis on the work undertaken by KPMG, our current fees paid and the work of the Task and Finish Group as set out in Figure 5 below. Page 8 of 17

9 Figure 5 above shows the current Birmingham average (shown in red), the KPMG Open Book 3 mean (inflated to reflect 2016 prices and to include a profit margin) shown in green and the fee proposed by the provider Task and Finish Group in 2016 (shown in purple). The Council s analysis shows that the current average paid for residential care for adults aged is below both the KPMG 2016 fee which uses the KPMG 2013 fee and inflates them to broadly 2016 levels - and the Task and Finish Group proposed fee. Unfortunately the Task and Finish Group did not provide a proposed fee for residential care for adults between years old with a physical disability to enable comparison. Unfortunately the KPMG analysis didn t separate out residential care and nursing care for year olds and as such, the fees shown in green on Figure 5 above are likely to include an element of nursing fees. The Council recognises there is no current fee structure for providers of adult social care for year olds and that the variance in fees above, may indicate that a revised approach is needed to link the eligible care and support needs to the price paid to providers. This is particularly relevant given the wide range of needs currently being met for this age group and also the range of fees which varies from xx to over 5,000 per week. The Council believes a fairer and more transparent fee structure is required particularly as there is no strong evidence base to support the variance in Page 9 of 17

10 fees between mental health, learning disability and physical disability services. Pricing assumptions As outlined in the Draft Commissioning Strategy the following general pricing assumptions have been adopted: Given the Council has proposed to delay implementation of the Birmingham Care Wage for 2017/18, the proposed fees will enable providers to pay their care workforce an hourly rate of 7.50, which is in line with the National Living Wage from 1 April 2017 and aligned to the Council s current Birmingham Care Wage. The Council s analysis has identified huge variances in the fixed costs associated with delivering care (the hotel or accommodation costs). Based on the analysis of all current data sources, there is no strong evidence base for these significant variances and as such, the Council is seeking to set a fixed accommodation cost across all bed-based categories of care. To reflect the complex range of support provided for those citizens with a learning disability, physical disability or mental health condition, a banded price model is proposed. This is based on the fixed accommodation cost, with a range of care costs added to reflect the complexity of each package of care. In addition to quality incentives and a wide range of support, the Council will make a commitment to review fees annually. This review will reflect a number of inflationary and pricing pressures placed on providers. The methodology for this is detailed in the Price Review Methodology section below. Providers will be expected to meet the CQC requirement that providers must provide sufficient numbers of suitably qualified, competent, skilled and experienced staff to meet the needs of the people using the service at all times and other regulatory requirements. Third Party Contributions (also known as top ups) will only be required when the person needing care or their family have specifically requested more expensive accommodation or are receiving a genuine upgrade in the services they are receiving. Page 10 of 17

11 The Council will invest in IT systems that ensure prompt payment and improve cash flows for care providers and to reduce financing and borrowing costs. Providers will be expected to take all opportunities available to reduce overheads, reduce transaction costs and increase occupancy levels to reduce the costs of care. All nursing related costs must be met through the Funded Nursing Care (FNC) or Continuing Health Care (CHC) contributions. The terms of the new framework will apply to new packages of care commissioned after 1 April 2018 only, including the proposed relevant fixed fee. All existing placements will remain under the current contractual arrangements as provided for in the necessary contract documents. The proposed fixed fees will be complemented by incentives and disincentives based on the quality rating of the provider as follows: In recognition of Gold rated providers that are exceeding the contractual and regulatory requirements and show leadership and innovation over a sustained period of time, the Council will pay a 2% quality premium for new packages. For those providers that are rated as Silver, they will be paid the standard fixed fee for the relevant category of care being delivered. Page 11 of 17

12 Providers that meet the Bronze quality standard will be paid a reduced fee if they fail to make the required improvements within the specific timescale. This is to incentivise improvements in quality to recognise that the necessary standards are not being met and that the provider should not be rewarded in the same way as a provider who is meeting the required standards. The 3% fee reduction is to ensure that the costs of care can continue to be met, but that the provider cannot continue to make a profit from the delivery of poor quality services. Price review methodology The Council recognises underlying price pressures within the care sector, particularly those in relation to employee costs, which make up the largest proportion of the cost of delivering care. The Council is committed to ensuring the care sector remains sustainable, not only as it delivers care to some of our most vulnerable citizens, but also as a major employer across the region. We will therefore review prices of care packages placed under the new contract on an annual basis using the following methodology: Change in Accommodation Costs = %age year on year change in CPIH (Consumer Price Index including owner occupiers housing costs) The Consumer Price Index with housing costs will be the Government s headline measure of inflation and not only covers a range of household expenses but also overall housing costs including Council Tax. The Council believes this to be a fair and objective measure of price pressures on housing and household related costs that would be included within a providers accommodation costs where appropriate. Change in Care Costs = %age year on year change in NLW (National Living Wage) or the Birmingham Care Wage, whichever is the greatest The Council will ensure that its fee structure continues to keep pace with the National Living Wage and the care costs within the fee structure will be amended in line with the year on year percentage change in the National Living Wage each year. The Council will use the annual change in inflation rate figures each year to calculate both the Change in Accommodation Costs and Change in Care Costs, with any price increases applicable from 1 April the following year. Page 12 of 17

13 Proposed prices for consultation home support, residential and nursing care over 65s and supported living The Council is proposing to pay the following fees for all new care packages purchased from 1 April These fees will be inflated to 1 April 2018 fees in accordance with the price review methodology above: Home support for children and young people with a disability and adults of all ages Residential care for adults over 65 Nursing care for adults over 65 Supported living (as defined by the Care Quality Commission) for adults of all ages Category of care Proposed Gold fee Proposed Silver fee Proposed Bronze fee* Comments Home support all ages per hour per hour per hour Based on the average price currently paid (as determined by the care market) for the period 1 April Jan This includes reduced travel costs/time in line with the proposed geographic home support model. Based on payment to all care staff of the National Living Wage rate of 7.50/hour from 1 April Based on an average of 30 hours employment per week. Supported living over 18 s per hour per hour per hour Based on the proposed home support fee, but with reduced travel costs/time. Residential care over 65 s per week per week per week Includes a proposed fixed accommodation fee of per week Page 13 of 17

14 Category of care Proposed Gold fee Proposed Silver fee Proposed Bronze fee* Comments Based on the average price currently paid (as determined by the care market) for the period 1 April Jan Residential care with nursing over 65 s per week per week per week Includes a proposed fixed accommodation fee of per week. These fees exclude any Funded Nursing Care contribution from the NHS. Residential care with nursing over 65 s per week including FNC per week including FNC per week including FNC These fees are for illustrative purposes only to show the total fee that nursing homes can expect to receive. The FNC contribution will not be paid by Birmingham City Council and must be claimed directly by the home from the relevant Clinical Commissioning Group. This includes the agreed FNC contribution of from 1 April * Bronze fee will only apply after a 3 month improvement period has been granted. Should the necessary improvements not have been made by the care provider then the fee will be reduced to the Bronze fee for all existing packages. All new placements from 1 April 2018 that are outside of the Birmingham City Council boundary will have regard to the cost of care in that area. Birmingham City Council will therefore match the host Local Authority fee for care. Proposed prices for consultation residential and nursing care for year olds To reflect the more complex range of care and support provided for those citizens between years old with a learning disability, physical disability or mental health condition, a banded price model is proposed. This Page 14 of 17

15 will ensure prices paid for care and support are directly linked to the amount of care and support required. It will also ensure a transparent and fair pricing structure for all providers. The proposed prices are based on the same fixed accommodation fee as for over 65 s (i.e ), with a range of care costs added to reflect the complexity of each package of care. Page 15 of 17

16 The proposed price bands are provided in the table below: Band Number of hours of care & support per week, per citizen Proposed Payment Point Total care hours element of fee Accommodation element of fee Total proposed Gold fee Total proposed Silver fee Total proposed Bronze fee Band Band Band Band , , , Band , , , Band , , , * Bronze fee will only apply after a 3 month improvement period has been granted. Should the necessary improvements not have been made by the care provider, then the fee will be reduced to the Bronze fee for all existing packages. Page 16 of 17

17 The table contained in Appendix 1 to this document gives an indication of the needs that will need to be met and should be delivered by care providers within each of the proposed bands above. Please note that this is not designed to be a complete list, but gives examples of the needs that are most likely to be met within the proposed price band. The proposed number of hours of care and support will be identified through an assessment of eligible care and support needs. For those citizens who have eligible care and support needs that are in excess of 102 hours per week, these will be calculated based on the following formula: (Number of hours of eligible care and support per week x per hour) + fixed accommodation fee = Total silver fee payable For example if a citizen had eligible care and support needs that were the equivalent of 120 hours per week, the following price would be paid: Total silver fee payable = (120 x 12.67) = = per week 120 being the number of hours of eligible care and support required per week being the proposed hourly rate based on the supported living cost of care per hour being the fixed accommodation cost proposed by the Council This will be adjusted according to the quality rating of the provider in line with the quality rating process outlined within the Draft Commissioning Strategy and the Quality Framework. All new placements from 1 April 2018 that are outside of the Birmingham City Council boundary will have regard to the cost of care in that area. Birmingham City Council will therefore match the host Local Authority fee for care. Page 17 of 17

18 Pricing Proposals Appendix 1 Needs to be met within proposed price bands Managing Nutrition Maintaining Personal Hygiene Managing Toileting Needs Being appropriately clothed Being able to make use of the adult s home safely Maintaining a habitable home environment Developing and maintaining family and other personal relationships Band 1 PEG feeding but independently managed. Unable to maintain some aspects of personal hygiene due to Able to use the toilet independently but might have physical impairment, requires assistance with some aspects of occasional accidents due to being forgetful or easily personal care, has full awareness of needs. distracted. Requires prompts/observations. May need support/reminders to attend to personal hygiene (lack of motivation/depression). May require a specialist diet - support with planning Through behaviour and or cognitive impairment does not Requires support with pad changing - requests this support preparation. Independent feeding with enablement potential. engage with occasional personal care routines and requires strategies like picture prompts or checklist in place to assist independence. Adult may have enablement potential. Able to manage most elements of dressing. Requires prompting to ensure clothing is appropriate/dressed correctly. Enablement potential. Safe with unsupervised time in own space, some awareness of support needs and can ask for help where needed Some awareness of own environment and need to maintain for safety and comfort. However, unable to maintain the environment safely without support - prompting and encouragement. Potential to develop these skills independently with planned support. Able to move safely around the home without support but Awareness of need to maintain environment and they are may have periods of illness that require additional support at able to participate in most domestic activities and have times (affects mobility) enablement potential. Unable to independently maintain family and other personal relationships - can request support as unable to initiate contact. Occasional supervision required due to frequent arising conflicts/inappropriate behaviours (relationships/sexual contact). Has awareness, can request support. Requires reassurance/guidance/prompts. Accessing and engaging in work, training, education or volunteering Requires a carer to be accessible on occasions engage in work or learning because of cognitive impairment or behavioural difficulties. Requires a shared carer to be accessible on occasions to engage in work or learning because of physical impairment. Making use of necessary facilities or services in the local community, including public transport and recreational facilities or services. Can access some parts of the community that they are familiar with as part of a routine and take appropriate action to safeguard themselves when out and about but needs support to access new areas/attend appointments. Can recognise risks in the community on familiar/planned routes but may struggle with unpredictable events in the community requiring telephone support. Potential for enablement. Band 2 Needs prompting to eat. May require structured routine around specific mealtimes. Can make simple cold snacks and drinks but requires support to prepare a main meal - enablement potential. PEG feeding that is independently managed unless there is an issue - they require support but can ask for it. Unable to maintain some aspects of personal hygiene, requires assistance with some aspects of personal care and transfers, has some awareness of needs, requires support of at least one person. Mobility issues limits ability to carry out some tasks relating to toileting (e.g. unable to undress without support). Able to manage most elements of dressing. Requires occasional support of one person. Will be able to participate in most tasks. May have anxiety/behaviours/safety of self/safety of Awareness of own environment and need to maintain for others/potential for property damage but can usually manage safety and comfort. Can participate in most domestic this by requesting support from staff. activities but requires support/prompting. Has enablement potential. Needs support with transfers so they can access their environment safely. Some awareness of own environment and need to maintain for safety and comfort. However, requires prompting and encouragement, is able to ask for support. Unable to maintain family and other personal relationships - may have an impact on wellbeing/behaviours. Requires occasional staff intervention. Requires a shared carer to be accessible regularly to engage in work or learning because of cognitive impairment or behavioural difficulties. Can use public transport for familiar routes but needs support for new routes - potential for travel training. Able to recognise most risks in the community but unable take appropriate action at all times to safeguard themselves when out and about. Requires support of staff most of the time but this could be shared with others. Band 3 Specialist diet - support with preparation. Requiring shared support to monitor feeding during meal times. Self neglect resulting in occasionally refusing to eat at times. Eating disorders/anxieties around food needing support. May require structured routine around all mealtimes. Can make simple cold snacks and drinks but requires all hot meals to be prepared. PEG feeding intervention from trained staff to start and finish. Dysphagia/specialist diet - requires input from other professionals (e.g. SALT). Specialist diet to be prepared. May need specific food preparation. Requiring shared support to monitor feeding during meal times. Through behaviour and or cognitive impairment does not engage with occasional personal care routines and requires prompting to maintain hygiene. Unable to maintain any aspect of personal hygiene, requires assistance with all aspects of personal care and transfers, unable to assist, is aware of needs, requires support of at least one person. Through behaviour and or cognitive impairment does not engage with some personal care routines and requires skilled support from 1 person to maintain hygiene. Requires support with pad changing - needs to be anticipated as unable/does not request support. Unable to use the toilet due to mobility problems and requires hoisting/hands on support from 1 carers. May be able to request support when needed. Needs occasional intervention due to removing clothing (sensory/behavioural) at home - responsive to prompting/instruction - support of one/shared carer. Unable to manage some elements of dressing due to physical or cognitive impairment. Requires support of one person. May be able to participate in most tasks. Unable to use the toilet due to cognition issues such as being Needs occasional intervention due to removing clothing unable to understand the process of or forgetting how to (sensory/behavioural) at home and in the community - perform the activities of using the toilet (e.g. undoing responsive to prompting/instruction - support of one carer. clothing and attending to personal hygiene). Unable to use the toilet due to communication issues such as not being able to tell someone. Able to move safely around the home if appropriate Awareness of need to maintain environment and they are aids/adaptations are in place but may require intervention at able to participate in most domestic activities but due to times. physical impairments they are unable to complete some full tasks without support. May have anxiety/behaviours/safety of self/safety of others/potential for property damage but distractions techniques are usually effective to avoid incident. Unable to recognise most risks in the home or take appropriate action in an emergency without instruction/direction. Support needs to be easily accessible at all times. Unable to access some areas in the home without support (mobility difficulties), unable to move around the environment safely without the support of at least one person. Awareness of own environment and need to maintain for safety and comfort. Can participate in some domestic activities but requires support. Limited awareness of own environment and need to maintain for safety and comfort. Can complete tasks but needs encouragement prompting and supervision. Not able to identify where support is needed. Awareness of need to maintain environment and they are able to participate in many domestic activities but due to physical impairments they are unable to complete the full task without support. Occasional supervision required due to frequent arising conflicts/inappropriate behaviours (relationships/sexual contact). Has awareness, can request support. Requires intervention of one member of staff. Unable to maintain family and other personal relationships - has an impact on wellbeing/behaviours. Requires occasional staff intervention. Occasional supervision required due to frequent arising conflicts/inappropriate behaviours (relationships/sexual contact). Has some awareness. Requires intervention of one member of staff. Requires a shared carer to be accessible regularly to engage in work or learning because of physical impairment. Requires the support of 1 carer to engage in work or learning because of cognitive impairment or behavioural difficulties. Requires the support of 1 carer to engage in work or learning because of physical impairment. Able to recognise some risks in the community and take appropriate action in most circumstances to safeguard themselves when out and about. Requires support of staff most of the time but this could be shared with another person. Can recognise risks in the community on familiar/planned routes but may struggle with unpredictable events in the community requiring staff support. Potential for enablement. Can use public transport but requires support of staff to ensure safety. Able to recognise risks in the community or take appropriate action to safeguard themselves when out and about. Requires support of staff all of the time but this could be shared with another person. Unpredictable/Predictable challenging and potentially dangerous behaviour when in the community requiring intervention by one staff member. Band 4 Self neglect resulting in occasionally refusing to eat at times. Eating disorders/anxieties around food needing skilled intervention. Requires structured routine around all mealtimes. Can make simple cold snacks and drinks but requires all hot meals to be prepared. PEG feeding requiring monitoring and support/intervention from trained staff. Dysphagia/specialist diet - requires input from other professionals (e.g. SALT). Specialist diet to be prepared. May need specific food preparation. Requiring support with feeding during meal times. Unable to maintain any aspect of personal hygiene, requires assistance with all aspects of personal care and transfers, unable to assist, no awareness of needs, requires support of at least one person. Through behaviour and or cognitive impairment does not engage with any personal care routines and requires skilled support from 1 person to maintain hygiene. Requires prompting/distraction techniques around behaviours (responds well/low level prompting) relating to smearing/manual evacuation/sensory needs resulting in eating soiled pads/gloves/eating faeces. Unable to use the toilet due to being doubly incontinent and Unable to manage some elements of dressing due to risk of skin breakdown requiring planned skilled intervention. physical/cognitive impairment. Requires support of one person. May be able to participate in some tasks. Requires occasional risk management around behaviours (may not always be responsive) relating to smearing/manual evacuation/sensory needs resulting in eating soiled pads/gloves/eating faeces. Needs regular intervention due to removing clothing (sensory/behavioural) at home and in the community - responsive to prompting/instruction - support of one carer. Support needs to be readily accessible to address arising Limited awareness of own environment and need to maintain issues - anxiety/behaviours/safety of self/safety of for safety and comfort. Can participate in some domestic others/significant property damage but this support does not activities but requires support. need to be in close proximity at all times. Unable to recognise most risks in the home or take appropriate action in an emergency without instruction/direction. Support needs to be easily accessible at all times. May need skilled intervention. Unable to access some areas in the home without support (mobility difficulties), unable to move around the environment safely without the support of at least one person. Limited awareness of own environment and need to maintain for safety and comfort. Can complete tasks but needs encouragement prompting and supervision to complete the tasks safely. Awareness of need to maintain environment and they are able to participate in some domestic activities but due to physical impairments they are unable to complete the full task without support. Unable to maintain family and other personal relationships - has a significant impact on wellbeing/behaviours. Requires occasional staff intervention. Regular supervision required due to frequent arising conflicts/inappropriate behaviours (relationships/sexual contact). Has some awareness. Requires intervention of one member of staff. Requires the skilled support of 1 carer to engage in work or learning because of cognitive impairment or behavioural difficulties. Requires the skilled support of 1 carer to engage in work or learning because of physical impairment. Need a specific form of transport due to inability to access public transport because of sensory and/or complex behavioural needs. Can share an escort/be transported with others. Unable to recognise many risks in the community or take appropriate action to safeguard themselves when out and about. Requires support of staff at all times. Unpredictable/Predictable challenging and potentially dangerous behaviour when in the community requiring intervention by more than one staff member. Self neglect resulting in occasionally refusing to eat at times. Eating disorders/anxieties around food needing skilled intervention. Requires structured routine around all mealtimes. Need all meals prepared. Unable to use the toilet due to mobility/cognitive problems and requires hoisting/hands on support from 1 carer. Support of at least one person needs to be readily accessible Very limited awareness of own environment and need to to address arising issues - anxiety/behaviours/safety of maintain for safety and comfort. Can participate in some self/safety of others/significant property damage but this domestic activities but requires support. support does not need to be in close proximity at all times. Regular observations need to be undertaken to ensure safety. Need a specific form of transport due to inability to access public transport because of sensory and/or complex behavioural needs. Can travel with others but requires an escort throughout the journey. Band 5 Problematic PEG feeding - requiring frequent monitoring outside the usual PEG maintenance routine. Requires skilled intervention. Unable to maintain any aspect of personal hygiene, requires assistance with all aspects of personal care and transfers, unable to assist, is aware of needs, requires support of at least two people. Unable to use the toilet due to being doubly incontinent and significant risk of skin breakdown requiring frequent skilled intervention. Unable to manage any element of dressing due to significant physical/cognitive impairment. Requires support of one person. Unable to recognise any risks in the home or take appropriate action in an emergency - requires some supervision and skilled intervention at all times. No awareness of own environment and need to maintain for safety and comfort. Ability to participate in any domestic activities is very limited. Unable to maintain family and other personal relationships - has a significant impact on wellbeing/behaviours. Requires regular staff intervention. Requires the skilled support of at least 2 carers to engage in work or learning because of profound cognitive impairment or behavioural difficulties. Unable to recognise any risks in the community or take appropriate action to safeguard themselves when out and about- requires close supervision at all times when out - Requires support by more than one staff member. Dysphagia/specialist diet - requires input from other professionals (e.g. SALT). Liquidised diet requiring monitoring and thickeners in fluids. Requiring close support with feeding (positioning etc.). Through behaviour and or cognitive impairment does not engage with most personal care routines and requires skilled support from 2 people to maintain hygiene. Unable to use the toilet due to non-compliance to prompts for example refuses to sit on the toilet due to anxiety/behaviour issues. Needs regular skilled intervention due to removing clothing (sensory/behavioural) at home and in the community - requires support of at least one person. Unable to access most areas in the home without support (significant mobility difficulties), unable to move around the environment safely without the support of at least one person. Awareness of need to maintain environments but is very Regular supervision required due to frequent arising limited in being able to participate in any domestic activities conflicts/inappropriate behaviours (relationships/sexual due to significant physical impairment. contact). Requires intervention of at least one member of staff. Requires the skilled support of at least 2 carers to engage in work or learning because of profound physical impairment. Unpredictable/predictable challenging and potentially dangerous behaviour when in the community requiring skilled intervention by one staff member and require access to a further staff member (possibly shared support). Self neglect resulting in refusing to eat at times. Eating disorders/anxieties around food needing skilled intervention. Requires structured routine around all mealtimes. Need all meals prepared. Unable to use the toilet due to mobility problems and requires hoisting/hands on support from at least 2 carers. May be able to request support when needed. Support of at least one person needs to be immediately accessible to address arising issues - anxiety/behaviours/safety of self/safety of others/significant property damage but this support does not need to be in close proximity at all times - eye line supervision. Very limited awareness of own environment and need to maintain for safety and comfort. Can participate in some domestic activities but requires 1:1 support. Need a specific form of transport due to inability to access public transport because of sensory and/or complex behavioural needs. Requires a skilled worker to accompany due to behaviours. Requires regular risk management around behaviours relating to smearing/manual evacuation/sensory needs resulting in eating soiled pads/gloves/eating faeces. Band 6 Problematic PEG feeding - requiring frequent intervention outside the usual PEG maintenance routine (pulling out/regurgitation). Requires skilled intervention. Unable to maintain any aspect of personal hygiene, requires assistance with all aspects of personal care and transfers, unable to assist, no awareness of needs, requires support of at least two people. Unable to use the toilet due to being doubly incontinent and significant risk of skin breakdown requiring frequent skilled intervention. No awareness when need intervention/unable to communicate when need intervention. Unable to manage any element of dressing due to significant physical/cognitive impairment. Requires support of more than one person. Unable to recognise any risks in the home or take appropriate action in an emergency - requires close supervision at all times (24 hours). Requires skilled intervention. No awareness of own environment and need to maintain for safety and comfort. Cannot participate in any domestic activities. Unable to maintain family and other personal relationships - has a significant impact on wellbeing/behaviours. Requires frequent staff intervention. Unable to engage in work or learning because of profound cognitive impairment or behavioural difficulties. Unable to recognise any risks in the community or take appropriate action to safeguard themselves when out and about- requires close supervision at all times when out - Requires skilled intervention by more than one staff member. Dysphagia/specialist diet - requires input from other Through behaviour and or cognitive impairment does not professionals (e.g. SALT). Liquidised diet requiring monitoring engage with any personal care routines and requires skilled and thickeners in fluids. Unable to feed independently support from 2 people to maintain hygiene. requires skilled intervention (positioning etc.). Problematic maintenance of colostomy bag/catheter requiring frequent skilled intervention. Needs frequent skilled intervention due to removing clothing (sensory/behavioural) at home and in the community - requires support of at least one person. Unable to access any areas in the home without support (significant mobility difficulties), unable to move around the environment safely without the support of at least one person. Awareness of need to maintain environments but cannot participate in any domestic activities due to significant physical impairment. Constant supervision required due to frequent arising conflicts/inappropriate behaviours (relationships/sexual contact). Requires intervention of at least one member of staff. Unable to engage in work or learning because of profound physical impairment. Unpredictable/predictable challenging and potentially dangerous behaviour when in the community requiring skilled intervention by more than one staff member. Self neglect resulting in refusing to eat. Eating disorders/anxieties around food needing frequent skilled intervention. Requires structured routine around all mealtimes with close supervision. Requires frequent risk management around behaviours relating to smearing/manual evacuation/sensory needs resulting in eating soiled pads/gloves/eating faeces. Support of at least one person needs to be immediately accessible at all times (24 hours) to address arising issues - anxiety/behaviours/safety of self/safety of others/significant property damage. Very limited awareness of own environment and need to maintain for safety and comfort. Cannot participate in any domestic activities due to their cognitive ability. Current/historical safeguarding concerns/court orders requiring supervised contact with family members/others. Need a specific form of transport due to inability to access public transport because of sensory and/or complex behavioural needs. Requires more than one skilled support worker to accompany due to behaviours. Unable to participate in any aspect of food preparation or feed themselves. Unable to use the toilet due to mobility/cognitive problems and requires hoisting/hands on support from at least 2 carers. Residential care with and without nursing for year olds